NJ DSRIP Planning Protocol Addendum 4 – DY6-DY8 Universal Performance Pool (UPP) Measures Catalogue

*Definitions and Acronyms are located at the end of this document.

Universal Code / Measure Name / DSRIP # / NQF
# / Measure Steward / NJ Data Source / Reporting Entity/ Setting of Care / Reporting Period / Eligible for Universal Performance Pool? / Eligible for or as a
Substitution for UPP?
30 / Hospital Acquired Potentially Preventable Venous Thromboembolism / 47 / Not Found / Joint Commission / Chart/
EHR / Hospital/ Inpatient Care / Annual; April / UPP / No
31 / Asthma in Younger Adults Admission / 14 / 0283
(based on) / AHRQ / MMIS / Department/ Inpatient Care / Annual; April / UPP / No
32 / Diabetes Short-Term Complications Admission Rate / 36 / 0272
(based on) / AHRQ / MMIS / Hospital/ Inpatient / Annual; April / UPP / No
33 / Ambulatory Care – Emergency Department Visits / 8 / Not Found / NCQA / MMIS / Department/ Emergency Department / Annual; April / UPP / No
34 / COPD Admission Rate / 32 / 0275
(based on) / AHRQ / MMIS / Hospital/ Inpatient Care / Annual; April / UPP / No
35 / Heart Failure Admission Rate / 45 / 0277
(based on) / AHRQ / MMIS / Hospital/ Inpatient Care / Annual; April / UPP / No
36 / Central Line-Associated Bloodstream Infection (CLABSI) Event / 21 / 0139
(based on) / CDC / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / UPP / No
37 / Postoperative Sepsis / 74 / Not Found / AHRQ / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / UPP / No
38 / Pediatric Central-Line Associated Bloodstream Infections (CLABSI) – Neonatal Intensive Care Unit and Pediatric Intensive Care Unit / 63 / Not Found / CDC / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / UPP / Yes
39 / Percentage of Live Births Weighing Less Than 2,500 grams / 67 / 0278 (based on) / CDC / MMIS / Department/ Inpatient Care / Annual; April / UPP / Yes
40 / Cesarean Rate for Nulliparous Singleton Visits / 23 / 0471 / Joint Commission / Chart/
EHR / Hospital/ Inpatient Care / Annual; April / UPP / Yes
41 / Elective Delivery / 37 / 0469 / Joint Commission / Chart/ EHR / Hospital/ Inpatient Care / Annual; April / UPP / Yes
42 / 30-Day All-Cause Readmission Following Heart Failure (HF) Hospitalization / 3 / 0330
(based on) / CMS / MMIS / Department/ Inpatient Care / Annual; April / No / Substitution
43 / 30-Day All-Cause Readmission Following Acute Myocardial Infarction (AMI) Hospitalization / 1 / 0505
(based on) / CMS / MMIS / Department/ Inpatient Care / Annual; April / No / Substitution
44 / 30-Day All-Cause Readmission Following Pneumonia (PN) Hospitalization / 4 / 0506
(based on) / CMS / MMIS / Department/ Inpatient Care / Annual; April / No / Substitution
45 / 30-Day All-Cause Readmission Following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization / 2 / 1891
(based on) / CMS / MMIS / Department/ Inpatient Care / Annual; April / No / Substitution

Definition Key:

Department–Refers to the New Jersey Department of Health

DSRIP Network– Refers to the DSRIP hospital’s outpatient (non-ED, non-inpatient) reporting entities. This may include the hospital-based clinic (as identified through hospital billing practices) a community-based reporting partner, or a combination of the two.

Hospital – Refers to the participating DSRIP hospital

Inpatient – Refers to the setting where care is received as a result of an admission order to a hospital.

OutpatientCare– Refers to outpatient, (non-ED, non-inpatient) ambulatory care. This may include physical health or behavioral health care.

Acronym Key:

AHRQ – Agency for Healthcare Research and Quality

AMA- PCPI – American Medical Association – Physician Consortium for Performance Improvement

CDC – Centers for Disease Control and Prevention

CMS – Centers for Medicare & Medicaid Services

EHR – Electronic Health Record

MMIS – Medicaid Management Information System

NCQA – National Committee for Quality Assurance

UPP – Universal Performance Pool

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